Minimizing member abrasion is a constant challenge for all payers. In fact, according to the 2023 Gartner Group CIO and Technology Executive Survey, improving the member experience is one of the top three enterprise priorities. To address this challenge, organizations typically look to care management practices, member engagement technologies, and even retrospective payment integrity.
However, one of the most effective ways to improve the member experience is to improve prospective payment integrity. That’s because a retrospective approach continues to add strain and create complexities that drives a wedge further between payers and their members. Prospective payment integrity improvements can eliminate many of the issues before they become challenges.
“By investing in a prospective payment integrity solution that highlights inaccuracies before the payment is made, you can stop the costly retroactive repayment process that negatively impacts your providers and members through administrative costs” – Gartner®, U.S. Healthcare Payer CIOs Must Invest in Prospective Payment Integrity to Improve Member Experience, 24 March 2023, Austynn Eubank, Mandi Bishop
When taking an enterprise-wide approach to payment integrity, payers should consider focusing on these four areas:
- Improve accuracy: To build trust with their members, payers must strive to be proficient and transparent in their payment integrity processes. Payment integrity platforms, such as Source, that offer a single API, automated and regular cloud-based updates, and a single source for fee schedules and payment policies, create a more seamless and centralized data source that informs more accurate payments.
- Address root cause payment issues upstream: The traditional approach to payment integrity is stacking third party payment recovery services on top of one another. Most of these services are based on contingency fees, so there is no incentive for these vendors to provide insight into the root cause of issues. As a result, payers continue to make the same mistakes month after month, never really having the opportunity to make meaningful changes that can deliver meaningful results.
- Take a member-centric approach to payment integrity: When payment integrity takes a singular, departmental approach that is focused on payment recovery, members are typically last in line for consideration. The responsibility of recovering inaccurate payments are then passed off to other departments who are left to deal with member communications. An enterprise approach to improving payment integrity and more accurate payments are made more often, there are fewer opportunities for member abrasion and less manual work for staff. Everyone wins.
- Shift to prospective payment integrity: Looking forward and improving payment accuracy in advance of payments makes logical sense, but until Source started delivering a transformative approach to payment integrity, the cost vs. value was simply not there. Forward-leaning payers who are implementing the Source Platform Access and suite of solutions are able to experience continuous process improvements across their enterprises, and ultimately reduce member abrasion while gaining significant efficiencies.
 Infographic: Top Priorities, Technologies, and Challenges for Healthcare Payers in 2023
 U.S. Healthcare Payer CIOs Must Invest in Prospective Payment Integrity to Improve Member Experience, Gartner 24 March 2023, Austynn Eubank, Mandi Bishop. GARTNER is a registered trademark and service mark of Gartner, Inc. and/or its affiliates in the U.S. and internationally and is used herein with permission. All rights reserved.